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NEUROLOGIC EVALUATION 1RN AMPARO SANCHEZ INSTRUCTOR ASSIGNMENT : NEUROLOGICAL DISORDERS & PRIORITIZING CLIENT CARE. Student: Answer the Assignment in the answer sheet that appears on the next slide and send your answers to the professor RN AMPARO SANCHEZ INSTRUCTOR 1- 7- 13- 19- 25- 31- 2- 8- 14- 20- 26- 32- 3- 9- 15- 21- 27- 33- 4- 10- 16- 22- 28- 34- 5- 11- 17- 23- 29- 35- 6- 12- 18- 24- 30- Answer Sheet Student Name ________________________________Cohort_______ Assignment : Neurological Disorders & Prioritizing Client Care. 5/10/2021 3Instructor Amparo Sanhchez 1.An assessing of a client´s orientation is best obtained by. 1-Asking the client´s name, where he lives, and what time it´s. 2-Asking the client to repeat a series of three digits spoken slowly. 3-Pointing to common objects and asking the client to name them. 4-Using Glasgow Coma Scale, and computing the score. RN AMPARO SANCHEZ INSTRUCTOR 4 Assignment Quiz. 2. A toddler has recently been diagnosed with Cerebral Palsy. Which of the following information should the nurse provide to the parents? Note: More than one answer may be correct. 1. Regular developmental screening is important to avoid secondary developmental delays. 2. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties. 3. Developmental milestones may be slightly delayed but usually will require no additional intervention. 4. Parent support groups are helpful for sharing strategies and managing health care issues. RN AMPARO SANCHEZ INSTRUCTOR 5 Quiz. 3.A Client who decreased LOC has urinary incontinence and excoriation in the perineal area. Which action should be a priority?  1-Keeping the perineal area clean and dry.  2-Offering the client the urinal every 3 hours.  3-Maintaining a fluid intake of 1 l/day.  4-Applying moist warm compresses to the clients groin. RN AMPARO SANCHEZ INSTRUCTOR 6 4-A client is admitted with the following Vital Signs:  Which nurse diagnosis should receive the highest priority?  1-Decrease cardiac output.  2-Ineffective thermoregulation.  3-Ineffective breathing pattern.  4-Ineffective renal tissue perfusion. 5-A 70-year-old client is confined to her bed due to advanced Parkinson´s disease. Which nursing diagnosis takes the highest priority for a client with Parkinson´s crisis? • 1-Imbalanced nutrition. • 2-Ineffective airway clearance. • 3-Impaired urinary elimination. • 4-Risk for injury RN AMPARO SANCHEZ INSTRUCTOR 7 -Temperature - 102ºF, -Pulse - 144 beats/minute and irregular, -Respirations - 26 breaths/minute. 6-During a late stage of AIDS, a client demonstrates signs of AIDS-related dementia. Which nursing diagnosis should receive the highest priority? • 1-Bathing or hygiene self-care deficit. • 2-Ineffective tissue perfusion (cerebral.) • 3-Dysfunctional grieving. • 4-Risk for injury. 7-A client is admitted with a cervical spine injury caused by a diving accident. When planning this client´s care, which nursing diagnosis should receive the highest priority?  1-Impaired physical mobility.  2-Ineffective breathing pattern related to the injuries  3-Disturbed sensory perception (gustatory).  4-Dressing or grooming self-care deficit. RN AMPARO SANCHEZ INSTRUCTOR 8 8-A client sustains a concussion during a motor vehicle accident and, on admission is disoriented and restless. Which nursing diagnosis should receive top priority?  1-Disturbed sensory perception (visual).  2-Dressing or grooming self-care deficit.  3-Impaired verbal communication.  4-Risk for injury. 9-Entering the client´s room to get the neonate for a examination by the physician, the nurse on the maternity unit sees the client holding the crying neonate and slapping his face. Which action is the nurse´s first priority?  1-Take the neonate to the nursery, tell the physician to examine the neonate for injuries, and notify the social service.  2-Leave the room with the neonate, and notify the nursing supervisor.  3-Confront the client by asking her what she´s doing and why.  4-Take the neonate to the nursery, and tell coworkers to observe the client for further incidents. RN AMPARO SANCHEZ INSTRUCTOR 9 10-A 2-year-old client is admitted for possible bacterial meningitis. Which of the following actions should the nurse take first?  1-Read the client history and physical examination report.  2-Assess the client neurologic status, admit him into Respiratory isolation  3-Interview the client´s parents.  4-Administer oxygen at 10 L/minute by nasal cannula. 11- A client admitted a cerebral contusion is confused, disoriented, and restless. When planning care, which nursing diagnosis should receive the highest priority?  1-Disturbed sensory perception (visual) related to neurologic trauma.  2-Feeding self-care deficit related to neurologic trauma.  3-Impaired verbal communication related to confusion.  4-Risk for injury related to neurologic deficit. RN AMPARO SANCHEZ INSTRUCTOR 10 12-The nurse is preparing to obtain a client history on a newly admitted client when the client suddenly loses consciousness. When assessing this client, what should the nurse do first?  1-Call for assistance.  2-Assess for responsiveness.  3-Palpate for a carotid pulse.  4-Assess for pupillary response. 13- An 8-year-old client is admitted to the hospital after being hit by car while riding a bicycle. The nurse´s assessment reveals the following findings: pale, cool arms and legs, capillary refill time of 6 seconds, heart rate of 135 beats/minute, and blood pressure of 100/80 mmHg The client is crying and asking for something to drink. Which should diagnosis the nursing do first?  1-Neuromuscular impairment.  2-Having a reaction to an antibiotic.  3-Developing circulatory failure.  4-Responding normally to stress RN AMPARO SANCHEZ INSTRUCTOR 11 14-A client with a brain tumor is admitted to an acute care facility: The nurse formulates a nursing diagnosis of risk injury. “Which related to” phase should the nurse add to complete the nursing diagnosis statement?  1-Related to visual field deficits  2-Related to difficulty swallowing  3-Related to impaired balance  4-Related to psychomotor seizure 15- The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available:  1-The client with Myxedema.  2-The client with Diabetes.  3-The client with Acromegaly.  4-The client with Cushing´s Triad. RN AMPARO SANCHEZ INSTRUCTOR 12 16-The nurse is doing bowel and bladder retraining for a client with paraplegia. Which of the following is not a factor for the nurse to consider?  1-Fluid intake.  2-Mobility.  3-Diet pattern.  4-Sexual function. 17-A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern?  1. Bulging anterior fontanel. 2. Repeated vomiting. 3. Signs of sleepiness at 10 PM. 4. Inability to read short words from a distance of 18 inches. RN AMPARO SANCHEZ INSTRUCTOR 13 18-The nurse is assessing a client´s extraocular eye movements as part of the neurologic examination.The nurse is assessing which cranial nerves?  1-Cranial nerve II  2-Cranial nerve III  3-Cranial nerve IV  4-Cranial nerve V  5-Cranial nerve VI  6-Cranial nerve VIII 19-Which of the following roommates would suitable for the client with Myasthenia Gravis?  1-A client with Crohn’s Disease  2-A client with Pyelonephritis  3-A client with Bronchitis  4-A client with Hypothyroidism RN AMPARO SANCHEZ INSTRUCTOR 14 20-The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to:  1-Ask the client to rate his pain on a scale of 0 to 10.  2-Take the blood pressure, pulse and Monitor restlessness.  3-Watch the client´s facial expression .  4-Ask the client if the is in pain. 21-The nurse has received the shift report and is preparing to make the rounds. Which client should be seen first?  1-The client with a history of a cerebral aneurysm with an oxygen saturation of 90% and shortness of breath.  2-The client with three days post-surgery ,coronary artery bypass graft with a temperature of 102 ºF.  3-The client admitted 1 hour ago with shortness of breath and ask for any drink.  4-The client being prepared for discharge following a femoral popliteal bypass graft. RN AMPARO SANCHEZ INSTRUCTOR 15 22-A client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept available during the test?  1-Promethazine  2-Furosemide  3-Prostigmin  4-Atropine sulfate. 23-The nurse is ready to do an examination on a 9-month-old infant. The child is sitting on his mother´s lap. What should the nurse do first?  1-Check the Babinski reflex.  2-Palpate the abdomen.  3-Check tympanic membranes.  4-Auscultate to the heart and lung sounds. RN AMPARO SANCHEZ INSTRUCTOR 16 24-A nurse observes that decerebrate posturing is a comatose client´s response to painful stimuli. Decerebrate posturing as a response to pain indicates?  1-Disfunction in the cerebrum,cortex and all ventricles  2-Risk for increased intracranial pressure  3-Disfunction in the brainstem  4-Disfunction in the spinal column. 25-Maslow´s hierarchy provides a theoretical foundation for establishing priorities. According to Maslow´s theory, which of the following has the highest priority?  1-The need to be loved by someone.  2-The need for physical safety and security.  3-The need for a treatment to alleviate dyspnea and pain.  4-The need to know about the critical thinking of the nurse. RN AMPARO SANCHEZ INSTRUCTOR 17 26-A client is admitted to an acute care facility for treatment of a brain tumor. When reviewing the chart, the nurse notes flexion in the client´s extremity in both arms, while the leg’s is extension. Which assessment finding should the nurse anticipate?  1-Normal, full muscle strength is present  2-Muscle move actively against gravity alone  3-Cerebral injury with decorticate posture  4-Muscle contraction or movements is undetectable 27-The nurse the is assessing the chart of a client with cerebral aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?  1-Check in the physician´s progress notes to see if understanding has been documented.  2-Explain the procedure and complications to the client.  3-Call the surgeon and ask him or her to see the client to clarify the information.  4-Check with the client´s family to see if they understand the procedure fully. RN AMPARO SANCHEZ INSTRUCTOR 18 28-The nurse arrives at work and is told to report (float) to the Emergency Room because the ER is understaffed and needs additional nurses to care for the clients injured in a tornado. Which client can be assigned to share a room in the emergency department during the disaster?  1-The client who is six months pregnant with abdominal pain and the client with facial pain and broken arm.  2-A client whose pupils and fixed and dilated and his parents, and a client with a frontal head injury  3-The client who arrives with a large puncture wound to the abdomen and the client with chest pain  4-A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis 29-The RN is marking assignments for a clients hospitalized on a neurological unit. Which client should be assigned to the LPN ?  1-A client with exacerbation of multiple sclerosis.  2-A client with C3 injury immobilized by Crutchfield tongs.  3-A client wit a lumbar laminectomy in hypertensive status.  4-A client hemiplegic and a severe urinary tract infection RN AMPARO SANCHEZ INSTRUCTOR 19 30-Which assignment should not be performed by the LPN?  1-Obtaining a sputum specimen and measure drainage contents.  2-Discontinuing a nasogastric tube and suction.  3-Inserting a Foley catheter and measure Ph.  4-Starting a blood transfusion and crosstmaching test. 31-Which client is most likely to receive opioids for extended periods of time?  1-A client with fibromyalgia.  2-A client with phantom limb pain.  3-A client with progressive pancreatic cancer.  4-A client with trigeminal neuralgia. RN AMPARO SANCHEZ INSTRUCTOR 20 32-A client with lung cancer has received Oxicodone 10 mg orally for pain. When the student nurse assesses the client . Which finding should you instruct to report immediately?  1-Respiratory rate 8-10 per minute.  2-Pain level decrease from 6/10 to 2/10.  3-Client requests room door be closed.  4-Heart rate 90-100 per minute. RN AMPARO SANCHEZ INSTRUCTOR 21 33- A client diagnosed with anasacoria the nurse know that this condition meaning: Select all that apply.(SATA)  1- Equal pupils and diplopia.  2- Unequal pupils.  3- Diplopia mean hemianopsia.  4-Ptosis.  5-Monitor for asymmetric pupils.  6- One reactive pupil and one dilated pupil in a comatose child is neurosurgical emergency that may require evacuation of the hematoma. 34- Client diagnosed with Hemianopsia, the nurse should:  1- Approach from intact side.  2- Encourage to severe physical activities.  3-Take Vital Signs every hour.  4-Assessment of Snellen’s chart. 22RN AMPARO SANCHEZ INSTRUCTOR 35-A nurse is performing a neurologic assessment on a 1-day old neonate in the nursery. Which finding indicate possible asphyxia in uterus? Select all that apply.  1-The neonate grasps the nurse´s finger when she puts it in the palm of his hand  2-The neonate does stepping movements when held upright with sole of foot touching a Surface  3-The neonate toes don´t curl downward when soles of the feet are stroked.  4-The neonate doesn´t respond when the nurse claps her hands above him  5-The neonate turns toward the nurse´s finger when she touches his cheek  6-The neonate displays weak, ineffective sucking RN AMPARO SANCHEZ INSTRUCTOR 23